Module 27, General Orthopaedist Level

This is a 3 year old girl who presented to the emergency room with a complaint of left foot pain exacerbated by bearing weight. The previous day the patient's 4 year old sister had jumped onto her left foot during play resulting in immediate pain and an antalgic gait. She had no pain in the left foot prior to this episode. She was evaluated and radiographs were obtained. The radiology report said this was consistent with Kohler's disease and no fractures were noted. The parents were told by their family doctor that this will go away on its own and no treatment is indicated. After she continued to limp for four weeks the family obtained another opinion.

Question 27A

The above information clearly provides evidence that this child has Kohler's disease.

Question 27B

At the time she presents at fours weeks after injury further work requires obtaining a bone scan.

Question 27C

In the course of further work up an x-ray demonstrated new periosteal reaction along the middle 3 metatarsals. This is probably evidence of a healing fracture.

Question 27D

With the above history and the periosteal reaction present in the multiple bones of the feet, child abuse should be suspected.

Question 27E

Comparison x-rays of the other foot would be most helpful to determine if this is Kohler's or normal variant.